Urge Incontinence Treatment Antimuscarinic Drugs

"When the signal comes, I can't make it to the bathroom." It is what those who complain of urgency say most in the clinic. They have no major other discomfort like frequency or a feeling of residual urine, but say that the urge to urinate is uniquely sudden and hard to hold. Such symptoms commonly appear in overactive bladder (OAB) and shake daily life, sleep, and even the freedom to go out not a little. In this article, we organize the symptoms of urge urinary incontinence and overactive bladder, and calmly look, from the perspective of the obstetrics-gynecology clinic, at what options exist, focusing on behavioral therapy and antimuscarinic medication.

Urgency refers to the symptom of a strong, hard-to-hold urge to urinate suddenly surging up. The case where, unable to hold this urge, urine leaks is called urge urinary incontinence. That is, if urgency is the symptom, urge urinary incontinence is the state in which that symptom has led to actual leakage.

Urge urinary incontinence differs in mechanism from stress urinary incontinence, which leaks when intra-abdominal pressure rises, as with coughing, sneezing, or exercise. Stress type is closer to the problem of the support structure of the pelvic floor muscles and urethra having weakened, and urge type is closer to the problem of the bladder itself becoming sensitive and contracting on its own. Mixed incontinence, in which the two exist together, is also not rare. Because the treatment direction differs according to which type it is, distinguishing which side your symptom is closer to is the first step.

In the clinic, in many cases the anxiety itself of "not knowing when the signal will come," rather than the amount that leaks, lowers quality of life more greatly. If you are curious about the types of incontinence, please also refer to the what types of urinary incontinence are there Q&A.

Overactive bladder is a state in which the bladder becomes sensitive from various causes and causes trembling or involuntary contractions. A normal bladder quietly waits until urine fills sufficiently, but in overactive bladder the bladder muscle contracts on its own before it is sufficiently filled and sends an urge signal.

Because of this, the following symptoms appear.

• Frequency: the number of times of urinating per day increases
• Urgency: a sudden, hard-to-hold strong urge to urinate
• Nocturia: waking one or more times during sleep because of urine
• Urge urinary incontinence: the case where urine leaks because the urge cannot be held

The cause does not come down to one thing. Bladder function changes with aging, hormonal changes around childbirth or menopause, neurological factors, and habits of caffeine or fluid intake act in combination. So even the same urgency has a different background from person to person, and the treatment is not uniform either.

If a stinging or sharp pain accompanies urination, there is a possibility of cystitis rather than overactive bladder, so it is better to first check the causes and treatment of cystitis with painful, stinging urination.

The starting point of treatment for urgency and overactive bladder is not medication but behavioral therapy. The 2024 overactive bladder care guideline of the American Urological Association and the Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction (AUA/SUFU) recommends proposing behavioral therapy first to all patients. The European Association of Urology (EAU) guideline also presents bladder training as first-line treatment.

The key is to retrain the bladder. The bladder, when trained, can increase its capacity and ability to hold. Rather than forcibly holding from the start, a way of gradually increasing the voiding interval by about 10 to 30 minutes per week is recommended. The goal is a state of being able to comfortably hold for 2 hours or more, and it is reported that when bladder training takes hold, the effect of medication also appears better.

Lifestyle habits are also adjusted together.

• Because caffeine stimulates the bladder, reduce intake of coffee, black tea, and energy drinks.
• Rather than drinking a large amount of water at once, take it appropriately, divided over the day.
• Doing pelvic floor muscle exercises (Kegel) in parallel can help manage the sense of urgency.
• Manage factors that burden the bladder, such as constipation, obesity, and smoking, together.

Such behavioral therapy has almost no side effects and can make a meaningful change without surgery, so it is worth trying first in any age group. If you are curious about treatment possible without surgery, the can urinary incontinence be treated without surgery Q&A also helps.

If urgency affects daily life to that extent, please do not endure it alone but receive a consultation. Consult about urgency symptoms

When behavioral therapy alone is not enough, medication is considered as the next step. For symptoms like frequency, urgency, and nocturia, two classes—antimuscarinics (anticholinergics) and beta-3 agonists—can be used, and in this article we explain centering on antimuscarinics, which have long been used.

Antimuscarinics block the muscarinic receptors in the bladder detrusor muscle and relax the detrusor. As the excessively contracting bladder calms down, symptoms like frequency and the sense of urgency decrease. Ditropan (oxybutynin), Detrusitol (tolterodine), Toviaz (fesoterodine), and Vesicare (solifenacin), which patients may have heard of in the clinic, all belong to this class. Propiverine, a first-generation drug, is relatively less used these days.

The drug is usually started at a low dose and adjusted while watching the response and side effects. Because judging the effect takes time, rather than judging from a few days of taking it, it is desirable to evaluate while taking it steadily for a certain period.

Antimuscarinics are drugs whose side effects must be considered together as much as they are effective. Representatively, constipation, dry mouth, blurred vision, tachycardia, urinary retention, and cognitive decline are reported. This is a phenomenon that appears because muscarinic receptors are distributed not only in the bladder but in many places such as the salivary glands, intestines, eyes, and brain.

In particular, in elderly patients, concern about cognitive function is great. Both the AUA/SUFU 2024 guideline and the EAU guideline explain that long-term use of antimuscarinics may be associated with the risk of cognitive decline and dementia, and that this burden may be cumulative and dose-dependent. So both guidelines recommend evaluating the total anticholinergic burden before starting the drug, and in many cases a beta-3 agonist is tried before antimuscarinics for reasons of safety.

For those worried about cognitive decline, an ingredient such as fesoterodine, which is known to relatively less cross the blood-brain barrier (BBB) and affect the central nervous system less, can be considered. However, because which drug is suitable has individual variation, consultation with a specialist is needed.

Also, antimuscarinics have the following contraindications or cautionary conditions, which must be checked before taking.

This table organizes general precautions, and whether to actually prescribe is decided through care.

There are also people whose symptoms do not improve satisfactorily even after sufficiently trying behavioral therapy and medication. In such cases, you should consider the possibility that multiple problems are intertwined behind the urgency.

Recent guidelines emphasize a direction in which the patient and the medical team choose options together, rather than the traditional way of going through the stages in order. Behavioral therapy, medication (antimuscarinics or beta-3 agonists), combination of the two drugs, and minimally invasive treatments such as neuromodulation—many options can be combined to suit the situation. If the response with the drug alone is insufficient, adding a drug of another class or moving to the next stage of treatment is the approach.

If symptoms persist for a long time, or if hematuria, pain, or symptoms of no urine output at all are accompanied, there may be a problem beyond simple overactive bladder, so a precise examination is needed. If you do not respond to medication, additional evaluation at a higher-level medical institution can help. If you have difficulty with voiding itself, please also refer to the voiding dysfunction item.

Whatever the route, the key is the same. Urgency and overactive bladder are not symptoms to endure, but a state that can be sufficiently managed with diagnosis and treatment. Since it can appear even in young women, knowing the early symptoms of urinary incontinence in advance also helps. If you are curious about the direction that fits your symptoms, please inquire about care for urgency and overactive bladder.

Author: Lee Dong-hee Chief Director · Obstetrician-Gynecologist · View staff profile

First published June 21, 2024 · Last reviewed May 30, 2026

References: AUA/SUFU Idiopathic Overactive Bladder Care Guideline (2024), EAU Non-neurogenic Female Lower Urinary Tract Symptoms Guideline (2024)

This article is intended to provide general health information and does not replace individual diagnosis or treatment. If you have symptoms, please consult through a medical examination.